2 IMPORTANT POINTSRecurrent Abdominal Pain (RAP) represents a description of symptoms, not a diagnosisThe most common cause of RAP is a functional gastrointestinal disorder (FGID)There are 4 major pediatric disorders associated with recurrent abdominal painFunctional abdominal pain syndromeFunctional dyspepsiaIrritable Bowel Syndrome (IBS)Abdominal MigraineA FGID is a positive diagnosisTherapy of a FGID is directed at environmental modification

3 Introduction RAP is not a diagnosisClinical manifestation of an organic disorder (23.6%)(Indian Pediatrics; 46: , 2009)Due to a FGIDDiagnosis of a FGID meets specific criteria (Rome III criteria)Red flag symptoms concerning for an organic disorderPain that awakens the childSignificant vomiting, constipation, diarrhea, bloating, or gasBlood in the stoolUnintentional weight loss or slowed growthChanges in bowel or bladder functionPain or bleeding with urinationAbdominal tenderness

5 Pathophysiology of FGIDsDifferent presentationsHeterogeneous group of disordersVariable expressions of the same disorderPrevailing viewpointPain is visceral in originInvolves disordered GI motilityInvolves visceral hypersensitivity/hyperalgesiaGenetic vulnerabilityAbnormalities in the enteric nervous systemDysfunction of the autonomic nervous systemAltered awareness of discomfort (emotions, cognitive processes, CNS influences)

6 General Approach to RAPHistoryComplete history is the MOST important component of the evaluation (Attempt to obtain directly from patient)Focus onTiming, frequency, location, quality of painAssociated GI symptoms (nausea, vomiting, diarrhea, constipation, blood in stool or emesis)Precipitating/relieving factorsSystemic symptoms ( fever, wt loss, joint pain, skin rash)Family History of IBD or PUDTravel HistoryMedication and nutritional interventionsInterference with school, play, peer relations, and family dynamics

7 General Approach to RAPPhysical ExaminationComplete and not only directed toward the abdomenGrowth data?Fall off in height or weight velocityDelay in pubertal developmentAbdominal examinationGeneral appearance, auscultation, palpation of liver and spleen, for masses and tendernessRectal examinationPerianal and digitalClubbing, rashes, arthritisPelvic examination (if indicated by history)

8 Rome Criteria III Functional Abdominal Pain SyndromeAt least 8 weeks of episodic or continuous abdominal pain in a school-aged child or adolescent occurring at least once/wk with one or more of the following:some loss of daily functioningadditional somatic symptoms such as headache, limb pain, or difficulty sleepingThe patient has insufficient criteria for other functional GI disorders that can explain the painNo evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptomsGastroenterology 2006;130:

10 Functional Abdominal Pain SyndromePain episodes begin graduallyLast less than 1 hr in 50%Last less than 3 hrs in 40%Continuous pain in < 10%Child is unable to describe the painRadiation of pain is rareTemporal relationship to meals, activity, bowel habits is unusual

11 Functional Abdominal Pain SyndromePain rarely awakens the child from sleepParents describe the patient as “miserable” and “listless” during pain episodesDuring severe attacks the child may exhibit a variety of motor behaviors (“doubling over in pain”)Common associated “autonomic” symptomsHeadache, pallor, nausea, dizziness, fatigueAt least one is observed in 50-70% of cases

13 Functional Abdominal Pain SyndromeDiagnosisThere is no dependable biological marker for functional abdominal pain syndromeMost reliable diagnostic features are the symptomsShould NOT require a series of diagnostic tests to rule out organic causes of painReasonable to obtain CBC, ESR or CRP, UA and culture, KUB, CMP, O+P, fecal leukocytes, lactose tolerance testing/lactose eliminationUS and CT are low yieldExcessive testing may increase parental anxiety and put the child through unnecessary stressParental anxiety/uncertainty increases the stressful environment that provokes and reinforces the pain behavior

14 Functional Abdominal Pain SyndromeTreatmentBegins at initial office visitImportant to introduce the concept of functional pain during the initial evaluationReview the differential diagnosis to reassure parents and child that specific organic disorders have been considered and “red flags” are absent

15 Functional Abdominal Pain SyndromeTreatmentFocus of treatment is not “cure” but management of symptoms and adaptation to illness to provide a satisfactory quality of life through support and educationAccomodative or secondary engagement coping (distraction, acceptance, positive thinking, cognitive restructuring) is related to less painPassive or disengagement coping (denial, cognitive avoidance, behavioral avoidance, wishful thinking) is associated with increased levels of pain

16 Functional Abdominal Pain SyndromeTreatmentDirected toward environmental modificationIdentify, clarify, and reverse stresses that may provoke or increase the perception of painReverse environmental reinforcement of the pain behaviorLifestyle MUST be normalized regardless of the continued presence of painParents should direct less social attention toward the symptoms

20 Rome Criteria III Functional DyspepsiaAt least 8 weeks (which need not be consecutive) in the preceding 12 months of persistent or recurrent pain occurring at least once/week centered in the upper abdomen ANDNo evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms ANDNo evidence that dyspepsia is exclusively relieved by defecation or associated with a change in stool frequency or formGastroenterology 2006;130:

28 Rome Criteria III Irritable Bowel SyndromeAt least 8 weeks in the previous 12 months of abdominal discomfort or pain occurring at least once/wk with at least 2 of the following:relief w/defecationonset associated w/change in frequency of stoolonset associated w/ change in form of stoolNo evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptomsGastroenterology 2006;130:

29 Irritable Bowel SyndromeMore common in adolescencePain is typically localized to the lower abdomenAssociation of pain with altered bowel patternDiarrhea (4 or more stools per day)Constipation (2 or less stools per week)Sense of incomplete evacuationStrainingUrgencyPassage of mucusFeeling of bloating or abdominal distentionPain is often relieved by defecation

33 Irritable Bowel SyndromeManagementSymptomatic and supportive careDevelopment of a positive relationship between doctor and patient/parentsValidate the symptoms that they are experiencingAddress the patient’s agenda by asking directly about their concerns and fearsInitial ManagementPositive, confident diagnosis communicated with clarity and honestyEducate about the pathophysiology of FGIDs and bring focus to the multifactorial nature of IBS

36 SummaryFGIDs can occur as a well defined clinical entity (e.g. IBS) or a less defined clinical syndrome (e.g. functional abdominal pain syndrome)Essential for physicians to take a biopsychosocial approach to diagnosis and treatmentAppreciate the close interaction of the gut and brainAllows the child, parent and physician to address the pain on many levelsFurther understanding of brain-gut axis and the role of serotonin in neural sensorimotor functions is needed

40 Irritable Bowel SyndromePsychological TreatmentStress managementPsychotherapyIntroduce early in the discussion of pathophysiology and management of IBSDo not leave as “last-ditch” treatment after medical therapy has proved less than optimalTherapy often combination of parent training, altering reinforcement of various behaviors and stress managementStatistically significant improvement of pain with adjunctive cognitive-behavioral therapy(J Consult Clin Psychol 57: , 1989, and 62: , 1994)